About 1.1 million students play on junior and high school football teams. Another three million play in non-school programs. Youth football is slowly dying. The number of players on junior and high school football teams has fallen 2.4% over the last 5 years. Pop Warner Football, the largest non-school based program has seen its number of student athletes fall 9.5% (23,612 athletes) from 2010 to 2012. Data is not available for other youth leagues.

Concussion: “The risk of having at least one concussion in any season of play and practice is anywhere from one in five players to one in twenty players. It is not known how many of these students suffer more than one concussion. After one concussion, that the risk of additional concussion(s) in that season or in a following season is increased three or four fold. A concussion increases the risk of a later catastrophic brain or neck injury that may result in paralysis or death. Studies show that football concussions are highly likely to cause headaches and difficulty concentrating or performing schoolwork for a week, several weeks or even longer.

Insurance: The team (has /does not have) a team physician/nurse to monitor for fitness to play. Such persons will try to detect athletes with concussions but their success at preventing concussions or other injuries is very limited. General medical insurance is the student’s responsibility. In the event of a catastrophic injury, the school does not provide or pay for long-term rehabilitation or vocational retraining, long term care or adaptive aids like crutches or wheelchairs. The school does not provide disability insurance for lost income.

The Dual Loyalty Problem of School Football

Medical ethics often addresses issues of dual loyalties. In such issues, the physician’s primary duty to a patient’s choice and well-being is potentially compromised by a contending personal interest or institutional pressure. Dual loyalty conflicts are seen in prison health care, military medicine, occupational medicine, research with human subjects and so on. Dual loyalties can affect a team physician or coach’s assessment and counseling of an aspiring football player. Risks may be minimized as students sign up to play. The potential for training, equipment, rules and refereeing to reduce concussions may be overstated. Injured players may be prematurely permitted or encouraged to ‘choose’ to return to play. Such issues affect the authenticity of choices of students who are also influenced by appeals to ‘school spirit,’ the mirage of a pro career, or peer pressure especially in smaller communities that have few candidates to fill a team roster.

Dual loyalty conflicts also work at an institutional level. School football is big business and a large part of popular culture. It is fiercely protected as is evident in the words of a judge who dismisses an injured player’s lawsuit for fear it might “harm” the sport.

However, the AAP’s report on youth tackle football balances health with the interests of the youth football industry. Its lead authors are experts on the clinical science of sports injuries but both coach sports where concussions are frequent. The report inexplicably omits discussing the effects of concussion on academic performance (the reason for going to school). It argues for respecting the ‘choice’ to play without noting how that schools, parents, coaches or the unrealistic aspirations for a pro career may pressure ‘choice’. It fails to offer an evidence-based template for informed consent, essentially preserving the current model of consent as a liability waiver. The report is optimistically speculative as when it suggests that neck strengthening might decrease the catastrophic neck injuries or cautions that that raising the age at which tackling is allowed might increase injuries. Throughout, the report upholds the tradition of youth tackle football against “fundamental change” even though scientific evidence is clearly trending in the opposite direction.

As long as football is played, primary prevention of injuries with the best equipment, coaching, rules of play and procedures for assessing and managing players will be needed.

However, we believe that this is a time for “primordial prevention” that remediates “environmental, economic, social and behavioral conditions, cultural patterns of living known to increase the risk of disease.” For health care professionals, primordial prevention might commend ending support for football in public schools. By this option, health professionals would oppose public support for bonds to build stadiums or athletic facilities for junior or senior high school football. They would oppose public school programs granting academic credit for playing football or leave of absences for practice or games. Such a proposal would not ban youth football. Private play and private leagues, like the Pop Warner program, would continue. Young people choosing such programs would play purely for the game and not be lured by ‘school spirit.’ Health professionals would continue to promote life long exercise programs and school physical education programs. However, under this proposal, the medical community could help students, schools and society leave a sport on which the sun is setting.

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